General Surgery Coding Alert

Although the AMA and CPT state that you shouldnt use 38792 and 78195 during the same session, following that advice could be costing your firm valid reimbursement. In part one of this two-part series on sentinel node biopsies, we discuss the proper method to report the imaging portion of these multistep procedures. Report Imaging Procedures Separately The sentinel node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other area of the body). Sentinel lymph node biopsy involves identification, removal and evaluation of lymph nodes that drain the area of a malignant tumor. The surgeon may use either of two methods, or a combination of both, to identify a sentinel node, says Donna J. Richmond, RCC, CPC, of Acadiana Computer Systems Inc., a billing, practice management software and services and consulting company based in Lafayette, La.:

1. Direct visualization (38792, Injection procedure; for identification of sentinel node): The surgeon injects the vital dye (such as isosulfan blue) shortly before surgery to stain the lymphatic vessels that drain the tumor site, thereby allowing him or her to identify the sentinel node. 2. Lymphoscintigraphy (78195, Lymphatics and lymph nodes imaging): This nuclear medicine procedure involves injecting a radioisotope, such as technetium-99, under the skin several hours prior to surgery. The isotope acts as a radioactive "tracer," which can be mapped by a gamma camera as it flows into the sentinel node and its lymphatic channel. Most often, a radiologist will perform this procedure, although a surgeon may on rare occasions perform and bill for it. Although 38792 and 78195 describe distinct procedures, the AMAs CPTAssistant (Dec. 1999: Vol. 9, Issue 12) instructs, "The injection of radioactive tracer is included in the lymphoscintigraphy procedure [78195] performed at the same session and is not reported separately. Therefore, it is inappropriate to report 38792 when lympho-scintigraphy is performed." This blanket statement suggests that 38792 is inappropriate even if direct visualization requires a separate injection (in other words, if the surgeon injects vital dye in addition to a radioactive tracer, you still may not report 38792 separately). CPT Assistant goes on to state, "In some cases, the physician will only perform the injection of the radioactive tracer, after which the patient will be sent for same-day sentinel node biopsy procedure with node identification performed using the operative handheld gamma detector. In this instance, nuclear medicine imaging lymphoscintigraphy is not performed. When identification through injection of a radioactive tracer of a sentinel node(s) is performed without scintigraphy imaging, report code 38792."

In other words, according to AMA/CPT guidelines, says Cindy Parman, CPC, a radiology coding and reimbursement specialist, member of the American Academy of Professional Codersnational advisory board and president [...]